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8/24/09

Must the doctor tell?

Randy Cohen takes up this question, in "The Ethicist" this week:

I am an anesthesiologist. Patients undergoing cardiac surgery routinely receive the intravenous blood thinner heparin, derived from pigs. Alternatives exist but are not F.D.A.-approved for this use and are probably less safe. Recently we had a devoutly Jewish patient. Should we have asked him whether a pig-derived product was acceptable or simply used what we knew to be most appropriate medically? Likewise, should we ask vegetarians about animal-based medical products? NAME WITHHELD, SACRAMENTO

His answer starts:

When in doubt, ask. The doctrine of informed consent is meant to put patients in control of their own care. It is the role of the doctor to provide the patient with the information needed to exercise that control. While you needn’t discuss heparin’s manufacture with all patients — most simply won’t care — you would do well to alert devout Jews or Muslims or vegetarians, who might have concerns about such things. more here

But it seems to me: the information is out there. Why is it the doctor's responsibility to provide it?

7 comments:

It's not the doctor's responsibility to inform the patient about all health matters concerning her treatment, not to guess or investigate what the patient's philosophical or religious or esoteric beliefs may be, given that there is an infinite offer of beliefs in today's supermarket of ideas.

I think it is interesting to note several different questions/claims in the article/post

"Must the doctor tell?" vs"Should we have asked [the patient]?" vs"Is it the doctor's responsibility to provide this information?"

there is a difference between 1. what would be good for the doctor to do, and 2. what we should *expect* the doctor to do and 3. what we should sanction the doctor if they don't do.

If your doctor knows that you are a devout religious adherent, and that you may have an objection to a medical product that they know contains animal products, the doctor *should* inform you that the drug she is about to prescribe is derived from pigs. It would be good for them do so (1).

And if you ask your doctor - does this drug contain animal products then the doctor should (stronger - probably 2, maybe 3) find out about the drug and let you know.

Whether we should expect them (2) or sanction them (3) if you haven't asked and they didn't tell you is less clear to me

Also there is another side to the responsibility. If your preference is idiosyncratic or unusual you, the patient, probably have a responsibility to find out which potential treatments may contain animal products, as well as to let your doctor know that you really don't want animal products (or blood products etc).

As a matter of fact, in a surgery situation, a doctor has so many things to think about: possible harmful drug interactions, allergic reactions, etc., that I would not want her to think about my dietary preferences, but to concentrate on my health. Any vegan who refuses to accept a drug with a small amount of animal material has made a religion, a purity issue, out of what should be a genuine concern with ending animal suffering.

What is it that's stopping me from agreeing with Randy--even with Dominic's refinements? I think I'm going to have to confess to thinking the doctor should be a little paternalistic. The patient is undergoing heart surgery. He has 1001 things to worry about. How could he really want yet another problem?

I'm also thinking about it practically. In my experience, surgery is all scheduled by the time the anesthesiologist makes contact with the patient. This happens the night before surgery, by phone. At that point, it's late in the game to be be discussing this issue.

In any event, if you don't want to eat a certain animal product, you learn early on that there's animal stuff all over the place, and in the most surprising places. So the patient can raise questions instead of the anesthesiologist offering answers unbidden.

Maybe I'd go the other way in an extreme case--where the anesthesiologist knows the patient personally and feels pretty sure that he would want to know.

Not only do doctors have a 1001 things to do and worry about, but many times unforeseen problems arise when the patient is under anesthesia, and the doctor needs the right drug and fast, from the stock of drugs at hand, not really the moment for the doctor or the nurse to read the fine print about the ingredients of the drug or to order a special drug from Whole Foods. Anyone who has seen a doctor functioning in an emergency or semi-emergency situation, giving orders to 2 or 3different nurses, who are as stressed as the doctor is, knows how utopian it is to expect the doctor to think about whether the patient is a vegan or not. Maybe in a boutique hospital, where you pay 5 thousand dollars a day for the room service (the New York Times often seems addressed to a public who pay more for lunch than I do for rent), but in a normal public or university hospital there is no time nor are there resources for such scruples.

How about a printout. Just stick it in front of the face of the dying patient. "I am the doctor trying to save your life, not preserve your system of do's and dont's, of no-no's and yesses (sp?) and other niceties. If you are offended by my life-saving procedures, you sure know what you can do about it. Bye bye. Sign here."

I had decaffeinated coffee this morning and am therefore unequipped to deal with these gentilities.